Your Medical Claim Gets Rejected?
Have you been paying your monthly RM250 Medical Insurance premium religiously for years, only to be frustrated by claim rejection when you most need it?
Original article from www.verywellhealth.com
Understanding the reasons why medical claims get rejected by insurers can help limit the number of denials your medical office receives. The only way to prevent them is to be aware of what they are.
Incorrect Patient Identifier Information
It is important to file a medical claim with accurate patient identifier information. Without this pertinent information, the health insurance plan cannot identify the patient to make the payment or apply the claim information is applied to the appropriate patient health insurance account.
Some of the most common mistakes that can cause a claim to deny due to incorrect patient identifier information are:
- The subscriber or patient’s name is spelled incorrectly
- The subscriber or patient’s date of birth on the claim doesn’t match the date of birth in the health insurance plan’s system
- The subscriber number is missing from the claim or invalid
- The subscriber group number is missing or invalid
Medical Insurance Coverage Terminated
Verifying insurance benefits prior to services being rendered can alert the medical office if the patient’s insurance coverage is active or has terminated. This will allow you to get more up-to-date insurance information or identify the patient as a self-pay.
Requires Prior Authorization or Precertification
Many services considered as non-emergency-related may require prior authorization. It is customary for most insurance payers to require prior authorization for expensive radiology services such as ultrasound, CT, and MRI. Certain surgical procedures and inpatient admissions may also require prior authorization.
Services that are provided to a patient that require prior authorization will likely be denied by the insurance payer. Services will not be denied if the services rendered are considered as a medical emergency. The provider may attempt to get a retro-authorization within 24 to 72 hours after the services are received depending on the insurance payers guidelines.
Medical Insurance Services Excluded or Non-covered
Exclusions or non-covered services refer to certain medical office services that are excluded from the patient’s health insurance coverage. Patients will have to pay 100 percent for these services.
This is another reason why it is important to contact the patient’s insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure.
Request for Medical Records
Some health insurance plans may request medical records when the claim requires further documentation in order to adjudicate the claim. The medical record includes but not limited to the following:
- Patient medical history
- Patient physical reports
- Physician consultation reports
- Patient discharge summaries
- Radiology reports
- Operative reports
Coordination of Benefits of Multiple Medical Insurance Plan
Coordination of benefit denials could include:
- Other insurance is primary
- Missing EOB (estimate of benefits)
- Member has not updated insurer with other insurance information
Coordination of benefits is a term used when a patient has two or more health insurance plans. Certain rules apply to determine which health insurance plan pays primary, secondary or tertiary. There are several guidelines to determine in what order the medical office must bill each health insurance plan.
Bill Liability Carrier
If the claim has been coded as an auto- or work-related accident, some carriers will refuse to pay until the auto insurance or worker’s compensation carrier has been billed.
For accident-related services, the following third party liability insurance should always be filed as primary:
- Motor Vehicle or Auto Insurance including no fault, policy or Med Pay
- Worker’s Compensation Insurance
- Home Owner’s Insurance
- Malpractice Insurance
- Business Liability Insurance
Missing or Invalid CPT or HCPCS Codes
In order for medical claims to process correctly, there are standard codes used to identify services and procedures. This system of coding is called the Healthcare Common Procedure Coding System (HCPCS and pronounced “hicks picks”).
Make sure your medical coders stay up-to-date on HCPCS codes. Changes to HCPCS codes are updated periodically due to new codes being developed for new procedures and current codes being revised or discarded.
Be aware of timely filing deadlines for each insurance carrier. Different Medical Insurance Carriers specify different period for timely filing deadlines, unless specified by law. They can range from as early as 30 days or within a year after the date of service. Read through your agreement to identify your insurance’s timely filing deadline period.
No Referral on File
Some procedures require that the patient obtains a referral from their family physician prior to services being rendered.
Life Engineering is NOT a Medical Insurance
We play by different rules. Making a claim is the part you do without when you enrolled in this program. The process is entirely between the hospital, PMA (Professional Medical Auditor), and Life Engineering. It’s done seamlessly in the background while you’re receiving your treatment. The only critical part is getting your Guarantee Letter approved. Once you’re admitted, you don’t have to think about any claiming process. The payment is done for you and wait for the end of the month when your sharing deposit will be deducted according to your bill amount and the number of current active Sharers. Rest assured, it will be no more than RM50 for one particular month.